Fundamentals of Nursing Nursing Process Questions

Correct Answer: E

Rationale: The correct answer is missing from the choices provided. However, for a client with an immune system disorder, essential nursing actions include: E: Educate the client on the importance of maintaining a healthy lifestyle, avoiding exposure to infections, and adhering to prescribed medications. This is crucial for managing the immune system disorder effectively. Incorrect choices: A: Following agency guidelines is important but doesn't specifically address the client's immune system disorder. B: Reviewing drug references may be necessary but is not a priority in managing the immune system disorder. C: Advising the client on modifying the home environment is not directly related to managing the immune system disorder. D: Monitoring the client for depression is important but not specific to addressing the immune system disorder.

Correct Answer: A

Rationale: The correct answer is A. 1. Change in level of consciousness is crucial in assessing neurological status. 2. Tachypnea indicates possible respiratory distress or oxygenation issues. 3. Tachycardia may suggest a cardiovascular problem or inadequate perfusion. 4. Petechiae can be a sign of bleeding disorders or sepsis. Option B is incorrect because chest pain, diaphoresis, and nausea/vomiting are more indicative of a cardiac event rather than monitoring for J.E.'s signs and symptoms. Option C is incorrect because loss of consciousness, bradycardia, and leg pain do not align with the signs and symptoms to monitor for J.E. Option D is incorrect because bradycardia, chest pain, and oliguria are not as comprehensive as the signs and symptoms listed in option A for monitoring J.E.

Correct Answer: C

Rationale: The correct answer is C: Diagnostic reasoning. The nurse is utilizing assessment data to analyze and interpret the information to develop a nursing diagnosis. This involves critical thinking skills to make conclusions and create a plan of care. A: Assigning clinical cues - This choice is incorrect as it refers to identifying objective and subjective data during assessment, not the process of analyzing and synthesizing data to form a diagnosis. B: Defining characteristics - This choice is incorrect as it typically refers to the specific manifestations or symptoms associated with a particular nursing diagnosis, not the process of diagnosing itself. D: Diagnostic labeling - This choice is incorrect as it refers to the final step in the nursing diagnosis process where the nurse assigns a label to the identified problem, not the overall process of diagnostic reasoning.

Correct Answer: C

Rationale: Correct Answer: C Rationale: 1. Potassium is typically administered on a secondary line to prevent rapid infusion and potential adverse effects. 2. The primary line carries the D5 � NS solution without potassium, while the secondary line delivers the potassium. 3. Reporting that "potassium is on the secondary line" accurately describes the setup for this IV infusion. Summary: A: Incorrect - Incorrectly states that the potassium bag is piggybacked into the dextrose. B: Incorrect - Closing the clamp below the D5 � NS bag is unnecessary and does not address the potassium infusion. D: Incorrect - Fails to address the specific issue of the potassium infusion being on a secondary line.

Correct Answer: D

Rationale: The correct answer is D: Evaluation. After implementing nursing interventions based on priority diagnoses, the nurse must evaluate the effectiveness of these interventions to determine if the desired outcomes have been achieved. Evaluation is crucial to assess the progress, make necessary modifications, and ensure the effectiveness of the care provided. Assessment (A) is already completed before interventions are carried out. Planning (B) involves developing a care plan based on assessment findings. Implementation (C) is the actual carrying out of the interventions. Therefore, the next step after implementing nursing interventions is to evaluate their effectiveness.